MEDICARE: MRS. AMANDA NICOLE TAYLOR PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA12858	TX

General Provider Information

NPI Number	:	1528629227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA NICOLE TAYLOR PA-C

Provider Business Mailing Address
First Line	:	P.O. BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8450
Fax Number	:

Provider Business Practice Location Address
First Line	:	5751 EDWARDS RANCH RD STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4120
Country	:	US
Telephone Number	:	817-332-8848
Fax Number	:	817-335-2670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2019
Last Update Date	:	03/03/2020

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